Stem Cell Oversight Committee (SCOC)

INSTRUCTIONS:
(Please print and complete by typewriter, or legible handwriting in black ink)

Applications must arrive at CIHR by June 2nd 2003 at the latest. Applications received after this date will not be considered.
Applications may come either directly from an interested individual, or from someone who wishes to nominate an individual as a member. In either case, the application must include all the elements listed below (3a-c).
Only complete applications should be submitted. Do not send any pages or parts of the application separately. A complete application includes the following:
1. Completed Stem Cell Oversight Committee Application/Nomination form;
2. Completed consent form; and
3. Two letters of reference from people with standing in your professional or home community. Must include complete contact information for those providing the letter of reference (phone number, e-mail address, fax, mailing address). If you are being nominated as a member, your nominator can provide one of these letters.
When filling in the application, please do not exceed the space provided for each part. Do not expand the boxes when filling in the form electronically.
You must enter your name on the top right corner of each page of the application.
Remember to sign the last page (applicant and nominator if applicable).
Send the original signed application and 5 COPIES by mail or courier to the address below. Please put the different parts of each copy in the order above (3a, 3b, 3c):
Barbara Beckett
Canadian Institutes of Health Research
410 Laurier Ave. W., 9th Floor
Address Locator 4209A
Ottawa, Ont. K1A 0W9

If you have questions, you may reach CIHR by phone, fax or e-mail.
Phone: (613) 941-2672 or 1-888-603-4178
Fax: (613) 954-1800
Email: stemcell@cihr-irsc.gc.ca

Part I - Applicant's / Nominee's Resumé

Last Name:		First Name:
Salutation (Mr., Mrs., Ms., Miss, Dr., Prof.)
Street Address (home):
City:		Province:
Country:		Postal Code:
Phone (home and cell):		Fax (home):
E-mail (home):
Current Employment
Title:		Start Year:
Employer:
Street Address (business):
City:		Province:
Country:		Postal Code:
Phone (business):		Fax (business):
E-mail (business):

Past Employment
Title:
Employer:
Start Year:		End Year:

Title:
Employer:
Start Year:		End Year:

Title:
Employer:
Start Year:		End Year:

Title:
Employer:
Start Year:		End Year:

Title:
Employer:
Start Year:		End Year:

Title:
Employer:
Start Year:		End Year:

Education
Institution:
Degree:
Year:

Institution:
Degree:
Year:

Institution:
Degree:
Year:

Institution:
Degree:
Year:

Institution:
Degree:
Year:

Institution:
Degree:
Year:

Additional training and education
Description	Year
1.
2.
3.
4.
5.

Awards Enter information on the awards that the applicant/nominee has won.
Description	Year
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Publications Enter your 7 most significant publications (not limited to peer-reviewed articles and books) from the last 5 years below. All publications must be entered on this form. Please do not submit a separate list of publications. NOTE: This section is primarily for academics. It is not necessary to have publications to be a SCOC member.
Title of article, chapter, etc.	Author(s), editor(s)	Name of journal, book, etc.	Volume	Pages	Year
1.
Significance:
2.
Significance:
3.
Significance:
4.
Significance:
5.
Significance:
6.
Significance:
7.
Significance:

Most Significant Achievements

Memberships Enter information on the nominee's memberships (on boards, committees, advisory bodies, etc.) below.
Description	Year
1.
2.
3.
4.
5.

Volunteer Experience
Description	Year
1.
2.
3.
4.
5.

Part II - Rationale for application/nomination

In the text box below, explain the rationale for applying or for nominating the candidate

Reason for candidate's interest:

Relevant experience & accomplishments:

Key strengths:

Expected contributions as a SCOC member:

Part III - Biographical Sketch of Applicant/Nominee

Summarize education, positions held, most significant awards and achievements

Part IV - SCOC Membership Category

Please indicate the membership category into which you would fit. Please check ALL boxes that apply.

__ Stem cell biology & therapeutics, developmental biology, embryology

__ Health care (in vitro fertilization specialist - e.g. physician, nurse, social worker)

__ Ethics

__ Law

__ Social science

__ Member of a health charitable organization

__ International member with expertise in stem cell research policy

__ In vitro fertilization patient

__ Member of the public not advocating for any special interest group

Part V - Nominator Information (if applicable)

Salutation (Mr., Mrs., Ms., Miss, Dr., Prof.)
First Name:		Last Name:
Title:
Organization:
Street Address:
City:		Province:
Country:		Postal Code:
Phone (business and cell):		Fax:
E-mail:

Part VI - Signatures

____________________________________
Applicant

__________________
Date

____________________________________
Nominator (if applicable)

__________________
Date

Part VII - Personal information - for administrative purposes only

English proficiency	French proficiency
Understand: __ Basic __ Good __ Very good	Understand: __ Basic __ Good __ Very good
Speak: __ Basic __ Good __ Very good	Speak: __ Basic __ Good __ Very good
Read: __ Basic __ Good __ Very good	Read: __ Basic __ Good __ Very good
Write: __ Basic __ Good __ Very good	Write: __ Basic __ Good __ Very good
Other Languages:
1.
2.
Gender: __ Male	__ Female

Please indicate dates when you would NOT be available for possible SCOC meetings:

June 2003
July 2003
August 2003
September 2003
October 2003

Common menu bar links

Funding

Public Involvement

Outcomes and Impacts

The Agency

Site Map

Proactive Disclosure

Useful Link

Application / Nomination Form

Part I - Applicant's / Nominee's Resumé

Current Employment

Past Employment

Education

Additional training and education

Awards

Publications